Section 154.2. Definitions

The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:

Act—Article XXI of The Insurance Company Law of 1921 (40 P. S. § § 991.2101—991.2193).

Ancillary service plan—As defined in section 2102 of the act (40 P. S. § 991.2102).

Clean claim—As defined in section 2102 of the act.

Commissioner—The Insurance Commissioner of the Commonwealth.

Complaint—As defined in section 2102 of the act.

Department—The Insurance Department of the Commonwealth.

Emergency service—As defined in section 2102 of the act.

Enrollee—A policyholder, subscriber, covered person or other individual who is entitled to receive health care services under a managed care plan. For purposes of the complaint and grievance processes, the term includes parents of minor enrollees as well as designees or legal representatives who are entitled or authorized to act on behalf of an enrollee.

Gatekeeper—A primary care provider selected by an enrollee or appointed by a managed care plan, or the plan or an agent of the plan serving as the primary care provider, from whom an enrollee shall obtain covered health care services, a referral, or approval for covered, nonemergency health services as a precondition to receiving the highest level of coverage available under the managed care plan.

Grievance—As defined in section 2102 of the act.

Health care provider—As defined in section 2102 of the act.

Health care service—As defined in section 2102 of the act.

IDS—Integrated Delivery System—

(i) A partnership, association, corporation or other legal entity which does the following:

(A) Enters into a contractual arrangement with a managed care plan.

(B) Employs or has contracts with providers (participating providers).

(C) Agrees under its arrangements with a managed care plan to do the following:

(I) Provide or arrange for the provision of a defined set of health care services to managed care plan members covered under a managed care plan benefits contract principally through its participating providers.

(II) Assume under the arrangements some responsibility for conduct, in conjunction with the managed care plan and under compliance monitoring of the managed care plan’s quality assurance, utilization review, credentialing, provider relations or related functions.

(ii) The IDS may also perform claims processing and other functions.

Licensed insurer—An individual, corporation, association, partnership, reciprocal exchange, interinsurer, Lloyds insurer and other legal entity engaged in the business of insurance, and fraternal benefit societies as defined in the Fraternal Benefits Societies Code (40 P. S. § § 1142-101—1142-701), and preferred provider organizations as defined in section 630 of The Insurance Company Law of 1921 (40 P. S. § 764a) and § 152.2 (relating to definitions).

Managed care plan—

(i) A health care plan that: uses a gatekeeper to manage the utilization of health care services; integrates the financing and delivery of health care services to enrollees by arrangements with health care providers selected to participate on the basis of specific standards; and provides financial incentives for enrollees to use the participating health care providers in accordance with procedures established by the plan. A managed care plan includes health care arranged through an entity operating under any of the following:

(A) Section 630 of The Insurance Company Law of 1921.

(B) The Health Maintenance Organization Act (40 P. S. § § 1551—1568).

(C) The Fraternal Benefit Societies Code.

(D) 40 Pa.C.S. Chapter 61 (relating to hospital plan corporations).

(E) 40 Pa.C.S. Chapter 63 (relating to professional health services plan corporations).

(ii) The term includes an entity, including a municipality, whether licensed or unlicensed, that contracts with or functions as a managed care plan to provide health care services to enrollees.

(iii) The term includes managed care plans that require the enrollee to obtain a referral from any primary care provider in its network as a condition to receiving the highest level of benefits for specialty care.

(iv) The term does not include ancillary service plans as defined by the act or an indemnity arrangement which is primarily fee for service.

Ongoing course of treatment—A continuous health care treatment provided to an enrollee by a health care provider which was initiated prior to and that will continue after the plan’s termination of a contract with a participating provider for reasons other than cause or the enrollee’s coverage by a managed care plan as a new enrollee.

Plan—As defined in section 2102 of the act.

Primary care provider—As defined in section 2102 of the act.

Prospective enrollee—For group contracts or policies, those persons eligible, but not yet enrolled, for coverage as either a subscriber or dependent of a subscriber. For individual contracts or policies, a person who meets the eligibility requirements of the managed care plan.

Provider network—As defined in section 2102 of the act.

Referral—As defined in section 2102 of the act.

Utilization review—As defined in section 2102 of the act.

Utilization review entity—As defined in section 2102 of the act.